Form 8963, Report of Health Insurance Provider Information

Instructions for Form 8963

Department of the Treasury
Internal Revenue Service

(Rev. February 2016)

Report of Health Insurance Provider Information
Section references are to the Internal Revenue
Code unless otherwise noted.

Future Developments

For the latest information about
developments related to Form 8963 and
its instructions, such as legislation
enacted after they were published, go to
www.irs.gov/form8963.
Note. See www.irs.gov/ACA9010 for
additional guidance.

General Instructions

electronic acknowledgment once you
complete the transaction. Keep it with your
records.

Where To File
If you are not filing electronically,
send your paper Form 8963 to
the following address.
Internal Revenue Service
1973 Rulon White Blvd.
Mail Stop 4916 IPF
Ogden, UT 84201-0051

Purpose of Form

File Form 8963 during each fee year (year
the annual health insurance provider fee is
due) to report net premiums written for
U.S. health risks during the data year
(calendar year immediately preceding the
fee year). The IRS will use that information
when figuring the annual fee imposed by
Affordable Care Act (ACA) section 9010.
(Public Law 111–148, section 9010; PL
111–148, section 10905; PL 111–152,
section 1406; and PL 113–235, division
M.)

Who Must File

Generally, a covered entity that provides
health insurance for any U.S. health risk
during the 2016 fee year (the calendar
year in which the fee must be paid) must
file Form 8963.

TIP

If you are not a covered entity,
you do not have to file this form.

When To File

You must file Form 8963 by April 18, 2016.

How To File

There are two ways to file your Form 8963.
1. You can file Form 8963 (with Form
8453-R, Declaration and Signature for
Electronic Filing of Forms 8947 and 8963)
electronically by accessing IRS e-file
using your own computer, or
2. You can file a paper Form 8963.
Note. If filing electronically, upload the
completed fillable version of the form. Do
not print and scan the form.

E-File: It’s Convenient, Safe and
Secure

IRS e-file is the IRS’s electronic filing
program. For more information about IRS
e-file, go to www.irs.gov/Form8963efile.
By filing electronically, you will receive an
Feb 02, 2016

TIP

If you mail your form, please also
fax it to 877–797–0235.

If you would like to request an
acknowledgment that we received your
Form 8963, please email LBI.IPF@irs.gov
with the company information and/or
tracking number and we will reply when
we receive the form. If you use an
overnight service, add the email address
LBI.IPF@irs.gov in the recipient email and
we will reply when we receive the form.

Public Disclosure

The information on this form is not
confidential. Although, generally, returns
and return information are confidential, as
required by section 6103, the information
on this form is not subject to section 6103,
pursuant to ACA section 9010, as
amended. All information on this form is
subject to public disclosure. Do not
include personal information other than
that requested by this form.

Definitions
Covered entity. Generally, covered
entity means any entity with net premiums
written for health insurance for U.S. health
risks during the fee year that is:
A health insurance issuer within the
meaning of section 9832(b)(2);
A health maintenance organization
within the meaning of section 9832(b)(3);
An insurance company that is subject
to tax under subchapter L, Part I or II, or
that would be subject to tax under
subchapter L, Part I or II, but for the entity
being exempt from tax under section
501(a);
An insurer that provides health
insurance under Medicare Advantage,
Medicare Part D, or Medicaid; or
A non-fully insured multiple employer
welfare arrangement (MEWA).

Cat. No. 60499R

Net premiums written. Net premiums
written means premiums written, including
reinsurance premiums written, reduced by
reinsurance ceded, and reduced by
ceding commissions and medical loss
ratio (MLR) rebates with respect to the
data year. Net premiums written includes
premiums written for assumption
reinsurance and is reduced by assumption
reinsurance premiums ceded. Net
premiums written does not include
premiums written for indemnity
reinsurance and is not reduced by
indemnity reinsurance ceded.
Assumption reinsurance is
reinsurance for which there is a novation
and the reinsurer takes over the entire risk
of loss pursuant to a new contract.
Indemnity reinsurance is an
agreement between one or more
reinsuring companies and a covered entity
under which (a) the reinsuring company
agrees to accept, and to indemnify the
issuing company for, all or part of the risk
of loss under policies specified in the
agreement; and (b) the covered entity
retains its liability to, and its contractual
relationship with, the individuals whose
health risks are insured under the policies
specified in the agreement.
In determining net premiums
written, filers must take
assumption reinsurance into
account by including assumption
reinsurance written in direct premiums
written and deducting assumption
reinsurance ceded from direct premiums
written. However, filers may not include
indemnity reinsurance written in direct
premiums written and may not deduct
indemnity reinsurance ceded from direct
premiums written.

TIP

U.S. health risk. A U.S. health risk
means the health risk of any individual
who is:
A U.S. citizen,
A resident of the United States (within
the meaning of section 7701(b)(1)(A)), or
Located in the United States, with
respect to the period that individual is so
located.
Health insurance. In general, the term
“health insurance” has the same meaning
as the term “health insurance coverage” in
section 9832(b)(1)(A), defined to mean
benefits consisting of medical care
(provided directly, through insurance or
reimbursement, or otherwise) under any
hospital or medical service policy or
certificate, hospital or medical service plan

contract, or health maintenance
organization contract offered by a covered
entity.
The term “health insurance”
includes limited scope (also
called stand-alone) dental and
vision benefits under section 9832(c)(2)
(A) and retiree-only health insurance, but
does not include any other excepted
benefits under section 9832(c).

TIP

For the definitions of controlled group,
single-person covered entity and
designated entity, see Specific
Instructions, next.

Specific Instructions
Covered entity information. A covered
entity is either a single-person covered
entity or a member of a controlled group. A
single-person covered entity is a covered
entity that is not a member of a controlled
group. Under the controlled group rule of
ACA section 9010(c)(3), all persons
treated as a single employer under
sections 52(a), 52(b), 414(m), or 414(o)
will be treated as one covered entity. In
applying the single employer rules, ACA
section 9010(c)(3)(B) provides that a
foreign entity subject to tax under section
881 is included within a controlled group
under section 52(a) or 52(b). A person is
treated as being a member of a controlled
group if it is a member of the group at the
end of the day on December 31, 2015 and
would qualify as a covered entity in 2016 if
it were a single-person covered entity.
Box 1. Single-person covered entity.
Check box 1 if you are a single-person
covered entity. You must sign Part I on
page 1 (see Part l signature instructions
below). Also complete the first line of
Schedule A.
Designated entity. Each controlled
group must have a designated entity.
If the controlled group, without regard
to foreign corporations included under
ACA section 9010(c)(3)(B), is also an
affiliated group that files a consolidated
return for federal income tax purposes, the
designated entity is the agent of the
affiliated group as identified on the tax
return filed for the data year.
If not, the controlled group must select
one of its members to be the designated
entity.
If a controlled group does not select a
designated entity, the IRS will select a
member of the controlled group as the
designated entity for the controlled group.
The designated entity is responsible for
the following for the group:
Filing Form 8963,
Receiving IRS communications about
the fee,

Filing any necessary error correction
report,
Paying the fee to the IRS,
Obtaining consents from all controlled
group members that are required to be
listed on Schedule A of this form, and
Providing (to the IRS upon request) the
consents obtained from controlled group
members that are required to be listed on
Schedule A of this form.
If the IRS selects the designated entity,
then all members of the controlled group
that are required to be listed on
Schedule A of this form will be deemed to
have consented to this election.
Box 2a. Agent of an affiliated group.
Check box 2a if you are the agent of an
affiliated group. You must also sign Part I
on page 1 (see Part I signature
instructions below). Also complete the first
line of Schedule A, with your National
Association of Insurance Commissioners
(NAIC) company and group code and net
premiums written, if any.
Box 2b. Other. Check box 2b if you are
the designated entity for a covered entity
that is not an affiliated group. You must
also sign Part I on page 1 (see Part I
signature instructions below). Also
complete the first line of Schedule A, with
your NAIC company and group code and
net premiums written, if any.
Corrected report. Check the box if this is
a corrected report.
Employer identification number (EIN).
Enter your EIN. If you do not have an EIN,
you must apply for one. If filing your Form
8963 electronically, enter your 9-digit EIN
without the dash. The EIN will be properly
formatted for you.
Number of controlled group members
included in Schedule A. Enter the
number of controlled group members who
are listed on Schedule A, including the
entity in box 2a or 2b. If reporting as a
single-person covered entity, enter “1” for
the number of controlled group members.
Entity name. If you checked box 1, enter
the name of the single-person covered
entity in the entity name box. If you
checked box 2a or 2b, enter the name of
the designated entity. If you have a trade
name or are doing business under a
different name, enter that name or d/b/a
name on the “Entity name (continued)”
line.
Address. Enter a street address where
you can receive overnight deliveries.

!

Do not provide a P.O. box.

CAUTION

Third party. If you receive your mail in
care of a third party (such as an
accountant or an attorney), enter on the
-2-

first street address line “C/O” followed by
the third party's name and enter the street
address where the third party can receive
overnight deliveries on the “Address
(continued)” line.
Foreign address. If reporting a
foreign address, include the full name of
the country using uppercase letters in
English. If you file Form 8963
electronically, select the full name of the
country from the drop down in the foreign
country name box. Enter foreign province
or state, and postal code.

Part I. Signature of Official
Signing on Behalf of the
Single-Person Covered Entity
or Designated Entity (Agent of
an Affiliated Group, or Other
Designated Entity) and Consent
by the Designated Entity (if
applicable)

Provide the date signed in MM/DD/YYYY
format, your phone and fax numbers, and
the name and title of your signing official in
print format.
If you file Form 8963 by paper,
manually sign the form.
If you file Form 8963 electronically, do
not manually sign the form. Instead,
manually sign, scan, and upload Form
8453-R with your Form 8963. See How To
File, earlier.

Part II. Alternate Contact
Person Designee

If you want to designate an employee to
discuss the report with the IRS, check the
related box and enter the person’s name,
title, phone number, and fax number, and
we will contact that person if we have any
questions concerning the report.

Schedule A. Single-Person
Covered Entity or Controlled
Group Member Information

Enter the single-person covered entity,
common parent of affiliated group, or
designated entity information on the first
line. This information will automatically
populate the first line of Schedule A if you
complete the form electronically. It is
unnecessary to repeat the entity name
and address from page 1 on line 1, but
you must enter all of the premium data
requested for the entity. Complete
additional lines for every person who is a
controlled group member at the end of the
day on December 31, 2015 and who
would qualify as a covered entity in 2016 if
it were a single-person covered entity, and
enter the following information for each
member.
(a) Employer identification number
(EIN). If filing your Form 8963
Instructions for Form 8963 (Rev. 02-2016)

electronically, enter your 9-digit EIN
without the dash. The EIN will be properly
formatted for you.
(b) Entity name. If you have a trade
name or are doing business under a
different name, enter that name or d/b/a
name.
(c) Address. Enter a street address
where you can receive overnight
deliveries.
If reporting a foreign address, also
include the full name of the country using
uppercase letters in English. Enter the
information in the following order: city,
province or state, and postal code.
(d) and (e) National Association of Insurance Commissioners (NAIC) identification codes. Enter (d) NAIC company
code and (e) NAIC group code for each
single-person covered entity, the common
parent of an affiliated group or designated
entity, and each listed controlled group
member. If you do not have an NAIC
company code or group code for a
covered entity or controlled group
member, leave the related field blank.
(f) Direct premiums written. For each
single-person covered entity or member of
a controlled group, the source of data for
determining direct premiums written is the
Supplemental Health Care Exhibit
(SHCE), filed with the NAIC; the Medical
Loss Ratio (MLR) Annual Reporting Form
(MLR form), filed with the Center for
Consumer Information and Insurance
Oversight (CCIIO); or any equivalent form
required by state or federal law. If the
entity or member does not file an SHCE,
an MLR form, or any equivalent form, the
entity or member is still required to file
Form 8963 and provide direct premiums
written for health insurance of U.S. health
risks and any other information required
by this form.
Generally, if the entity files an SHCE
and/or an MLR form, enter the direct
premiums written as reported for the data
year on the SHCE (SHCE, Part 2, line 1.1,
columns 1-10 plus 12) and/or MLR (MLR
form, Part 2, comparable lines and
columns, amounts from the “Total as of
12/31/Data Year” columns only).
References to the SHCE and the
MLR Form in these instructions
CAUTION
are solely for your convenience in
identifying the premium information
required for this report and are subject to
change.

!

Only include direct premiums written
for health insurance of U.S. health risks.
Exclude from direct premiums written any
premiums for coverage that is not health
insurance for U.S. health risks. For more
information see the definitions of Health
insurance and U.S. health risk, earlier.
Instructions for Form 8963 (Rev. 02-2016)

For any covered entity that files the
SHCE with the NAIC, the entire amount
reported on the SHCE as direct premiums
written will be considered to be for health
insurance of U.S. health risks (subject to
any applicable exclusions for amounts that
are not health insurance) unless the
covered entity can demonstrate otherwise.
If the entity does not file an SHCE with
NAIC or an MLR form with CCIIO, or those
forms do not contain the relevant data for
determining all of the direct premiums
written for health insurance for U.S. health
risks of an entity (or member), enter
comparable direct premiums written
information from any equivalent form
required by state or federal law.
If no single form contains all of the
relevant data for determining all of the
direct premiums written for health
insurance for U.S. health risks of an entity
(or member), then direct premiums written
must be determined using aggregated
data from multiple forms. Please include a
reconciliation with the premiums you
reported on the SHCE, MLR form, or
equivalent form required by state or
federal law.
Note. Notice 2016-14 addresses how to
treat direct premiums written for expatriate
health plans for the 2016 fee year. See
Notice 2016-14 for additional information.
(g) MLR rebates. Enter MLR rebates as
you reported for the 2015 calendar year
to: NAIC on SHCE; CCIIO on the MLR
form; or any other regulatory authority that
specifically requires MLR Rebates for
other than commercial markets (Medicare
Part D, Medicare Advantage, Medicaid,
FEHBP, etc.).
Figure the MLR rebates (current year
accrual), as below.
1. Rebates paid

. . . . . . . . .

2. Less estimated rebates
unpaid-prior year . . . . .
3. Plus estimated rebates
unpaid-current year . . .

. . .

. . . .

4. MLR rebates (current year
accrual). Enter this net amount in
column (g). Place a minus sign in
front of amounts to indicate
negative amounts. . . . . . . .

$ ________
$ (_______)
$ _______

$ _______

(h) Stand-alone dental or vision direct
premiums written. Enter the amount of
stand-alone dental or vision direct
premiums written as reported to the NAIC
on the SHCE. If you do not file an SHCE,
include direct premiums written for
policies providing for dental only or vision
only coverage issued as a stand-alone
dental or vision policy, or as a rider to a
medical policy through deductibles or
out-of-pocket limits.
-3-

(i) Net premiums written. Enter the total
of column (f) minus column (g) plus
column (h) in column (i).

(f) − (g) + (h) = (i)
This is 100% of the amount of net
premiums written for health insurance of
U.S. health risks for the calendar year.
The IRS will compute net premiums
written taken into account (in accordance
with Regulations section 57.4(a)(4)). If
negative, enter “0”. Any negative amounts
will be treated as zero for fee calculation
purposes.
(j) Amount in column (i) attributable to
section 501(c)(3), 501(c)(4), 501(c)
(26), or 501(c)(29) entities. All
designated entities or controlled group
members who enter an amount in box j
must be organized as a tax exempt entity
under section 501(c)(3), 501(c)(4), 501(c)
(26), or 501(c)(29).
Box 1 (or drop down menu). Enter
the section 501(c) paragraph number for
each entity that qualifies for the partial
exclusion, if applicable. Allowable
selections are 3, 4, 26, or 29. The entity
must be one of these types of entities in
order for it to qualify. If you file Form 8963
electronically, select the number of the
paragraph from the drop down box.
Box 2. Enter the portion of net
premiums written included in the total
reported in column (i) for health insurance
premiums that are attributable to certain
exempt activities of a covered entity
qualifying under section 501(c)(3), 501(c)
(4), 501(c)(26), or 501(c)(29) (ACA
section 9010(b)(2)(B), partial exclusion for
certain exempt activities).
Enter 100% of the premiums that
qualify for the exclusion and the IRS will
apply the 50% reduction after application
of the percentage of net premiums written
(see (i) Net premiums written, earlier). If
the amount entered is greater than the net
premiums written reported in column (i), it
will be limited to the amount of column (i)
for that controlled group member for fee
calculation purposes.

Error Correction Process

Each fee year, the IRS will send a
preliminary fee notification to each
covered entity. If the entity believes there
is an error in the notification, the entity
must submit a corrected Form 8963 in the
time and manner specified in the
notification.
Note. If you submit a corrected Form
8963 by e-file, you should receive an
electronic acknowledgement when you
complete the transaction. If you use
another method specified in the

notification, the IRS will mail an
acknowledgement to the address
indicated on the corrected Form 8963. If
you do not receive an acknowledgement
within 10 days of submission, please
contact the IRS by phone at 616-365-4617
(not a toll-free number), by fax at
877-797-0235, or by email at
LBI.IPF@irs.gov.
Disclosure and Paperwork Reduction
Act Notice. We ask for the information on
this form to carry out the Internal Revenue
laws of the United States. You are
required to give us the information. We
need it to ensure that you are complying
with these laws and to allow us to figure
and collect the right fee.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act

unless the form displays a valid OMB
control number. Books or records relating
to a form or its instructions must be
retained as long as their contents may
become material in the administration of
any Internal Revenue law.
Public disclosure, open to public
inspection. Although, generally, returns
and return information are confidential, as
required by section 6103, the information
on this form is not confidential and is not
subject to section 6103 pursuant to ACA
section 9010, as amended. All information
on this form is subject to public disclosure.
Do not include personal information other
than that required to be disclosed.
The time needed to complete and file
this form will vary depending on individual
circumstances. The estimated average
time is:

-4-

Recordkeeping . . . . . .

5 hr., 30 min.

Learning about the
law or the form . . . . . .

53 min.

Preparing the form . .

1 hr., 1 min.

Comments. You can send us
comments by going to www.irs.gov/
formspubs, clicking on “More Information,”
and then clicking on “Give us feedback.”
You can also send your comments to the
Internal Revenue Service, Tax Forms and
Publications Division, 1111 Constitution
Ave. NW, IR-6526, Washington, DC
20224. DO NOT SEND THE FORM TO
THIS ADDRESS. Instead, see Where To
File, earlier.

Instructions for Form 8963 (Rev. 02-2016)